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Dr. Marc Rosen (left) and Dr. Steve Martino at VA Connecticut Healthcare System are co-investigators for a new study that uses the compensation and pension exam to reach Veterans who are experiencing chronic pain. (Photo by Jhunathyn Ellis)
Dr. Steve Martino is chief of psychology at the VA Connecticut Healthcare System and professor of psychiatry at Yale School of Medicine. He specializes in the treatment of patients with substance use disorders, including those with co-occurring conditions. He also does research in the area of implementation science and how to move best practices into real-world clinical settings.
Dr. Marc Rosen is an addiction psychiatrist at the VA Connecticut Healthcare System and professor of psychiatry at Yale School of Medicine. He is the director of addiction recovery services at VA Connecticut, and conducts research on substance use disorders and related problems for affected Veterans.
VARQU spoke with the two researchers about their work on chronic pain management among Veterans.
The Department of Defense, National Institutes of Health, and VA have just co-funded a large grant to study non-drug approaches to pain management. What is the significance to the VA health system?
Dr. Rosen: This project has the potential to engage Veterans early in non-opioid pain treatment, and interrupt what can really be a harmful and dangerous course.
Podcast: Reaching Veterans with chronic pain
How did VA Connecticut become part of the larger grant?
MR: There are about 600,000 post-9/11 Veterans who are service-connected for back or neck pain. We had a developmental grant to intervene with people who were applying for service connection for musculoskeletal disorders. In the pilot study, most of the Veterans applying for service-connection for musculoskeletal disorders had considerable pain and impairment, and a high proportion were engaged in risky substance use. We found that they were amenable to intervention and that it helped them engage in VA pain-related treatment.
Dr. Martino: In addition, we also found that as a result of the early intervention, Veterans reduced their risky substance use, as well. So we thought that this was a very promising approach to bring forward to the grant application.
Can you tell us about your study, "Screening, Brief Intervention, and Referral to Treatment for Pain Management"?
MR: That's the title of the study, actually; it’s not the title of the grant. I like the title of the grant better, it's more descriptive. The title is actually a pretty good summary: "Engaging Veterans Seeking Service Connected Payments in Pain Treatment."
So why is that a good point in time to have this discussion with Veterans? Why not in the clinician's office?
SM: Well one of the main reasons is these Veterans may not be in the health service system of the VA. They are reporting problems they are experiencing, and may not be aware of the services they could avail to help themselves. There's traditionally been a limited amount of information provided to Veterans at the point at which they are seeking a disability compensation exam, just because the nature of the exam is really determination for disability, not a clinical assessment.
Marc's work has been fairly innovative in trying to use this as a point to provide Veterans who are seeking disability evaluations an opportunity to learn more about what is available to them and try to engage them in various services. And so that's why we think this is a great opportunity to work with Veterans who are experiencing chronic pain and who may have risky substance use—to try and get them engaged in services that they currently are not participating in.
Can you walk us through a brief description of this intervention?
MR: We talk to the Veterans a little bit about their claim: We ask them about their pain and inform them of the variety of services available at the VA health care system. We explain that pain treatment can involve not only medication, but also attending to other aspects of whole-body health. We then allow that many people in pain drink or use drugs to relieve their pain, and ask the Veteran about the extent of his or her substance use.
There's a format for this type of brief substance use counseling that Dr. Martino is an expert in. We follow that format to engage Veterans in reducing their substance use. That style of working with people is based on motivational interviewing. And so a large part of what we are doing is to motivate Veterans to participate in non-drug treatments, and commit to reducing or stopping their risky substance use. And engaging in specialized addiction services if that makes sense and they are willing to do so.
Part of the counseling involves not giving people exactly what they are expecting. The Veterans are coming for a compensation claim, and we are trying to say, "Hey, there are also some treatments available here that you are entitled to—that you've earned." We are also taking Veterans whose presenting complaint is pain and saying, "Substance use is something that could make your pain worse. Here are some ways you might want to think about that." We think that Veterans who have filed a claim are at a teachable moment.
How is motivational interviewing different from a traditional doctor/patient interaction?
SM: Motivational interviewing has been around for several decades. It began in the risky alcohol use field, and then has cut across all types of behavioral problems where motivation is part of the issue—particularly in the medical field. So the style of interaction really involves being very patient-centered, being empathic, collaborative, being compassionate to the needs of patients, and in particular being attentive to the ways in which patients speak about their problems that might support them making a change.
So what people do when using motivational interviewing as a framework is try to illicit or draw out people's reasons for change and get people to elaborate more about those matters, such that they talk themselves into changing based on their own motivation. It's a way of helping people talk themselves into changing based on what is unique about their own experiences.
You mentioned whole-body wellness earlier. Many studies show that opioids are not effective for long-term pain. What are some of the other treatments that might help patients deal with their pain?
MR: There are non-opioid medications. There are various physical treatments like physical therapy, exercise and activity, chiropractic services. There are mind-body based treatments like yoga and mindfulness. And there are psychological treatments like cognitive behavioral therapy and relaxation techniques. And finally, treating other issues that make pain worse: poor sleep makes pain worse, depression makes pain worse. Treating conditions that we know how to treat well can make a big difference.
SM: The mantra is that people need multi-modal pain care, and that the idea of medication as the sole form of treatment for chronic pain relief is misguided. We are trying to help people find a variety of ways in which they can approach pain treatment in order to get the best possible outcomes.
MR: There is a vicious cycle that people in pain can get into, in which they become less active, which is depressing. They don't sleep well which worsens their overall physical condition, which worsens their pain. A lot of these treatments involve interrupting that vicious cycle.
Can you tell us about the different phases of your study?
SM: For all of these grants, there is an initial preparation phase where we have to meet certain milestones to prepare for the pragmatic trial. That's a two year process. And at the end of the two years, those grantees who are successful in meeting their milestones presumably will continue to be funded for a four-year pragmatic trial. And we fully expect to be successful and be funded for pragmatic trial.
We have several things that we will be doing in phase one. First because we will be moving from the pilot trial which was done at VA Connecticut to all eight medical centers in VISN 1, we will get a grip on how pain care services and addiction services are delivered at each of those medical centers.
We will be doing semi-structured interviews and qualitatively analyzing them, to appreciate the various factors that are at play at each medical site. We'll be talking with community medical providers and administrators and primary care folks, including nurse care managers, and anyone else who can tell us what's unique about their medical center.
We will also be pilot testing this early intervention with five Veterans at each of the medical centers. The original trial was done face-to-face, in person. For this trial we will be using a hub-and-spoke model—so they'll be clinicians based in VA Connecticut who will be delivering the intervention entirely by phone. We want to see how that goes and if there are any adjustments that we need to make before we go to the full trial.
Another key feature of the two-year preparation phase is it is very hard to characterize Veterans' use of non-drug treatments. There aren't codes for many of these treatments in the electronic medical record. So we have partnered with investigators from George Washington University to use what's called natural language processing, to develop algorithms that will basically use computer programs to screen CPRS (Computerized Patient Record System) for Veteran's use of non-drug treatment modalities.
Another important piece of this study is the cost-effectiveness. How much is this all going to cost? And what kind of impact will this have on the budgets of medical centers, if they wanted to implement this if we were to be successful? So we also have a health economic component to this, and we will also be devising our methods for costing out everything for the trial.
If this all works, would it be something that the clinicians could provide at the different medical centers, or would it be delivered through telehealth?
SM: One of the reasons why we decided to do this within a VISN is because the VA is organized in regions—networks of medical centers organized together. Our hope would be if we could demonstrate this hub-and-spoke model, centered in a VISN, is effective, then it could be replicated in many other VISNs across the country. So we would be advocating for a telehealth means of administering this, which would provide greater access to people who may not be able to physically get to a medical center or who receive most services at rural sites across the country.
MR: One feature of the VA that would facilitate the adoption of this is that VA regions receive capitated payments for each Veteran, but the amount of payment is based on what services the Veteran receives. So if a Veteran comes to a hospital and only has a compensation and pension exam, that region gets a limited amount of money. If providers engage the Veteran in treatment, the region gets more money for that Veteran. So unlike in some other healthcare systems, the region doesn't lose money by providing more comprehensive care.
What are your long-term goals for this study?
MR: Our first goal is to test the intervention as proposed. We tested this at a single site: It was done through face-to-face encounters, and it was promising. This next study is needed to see if it works in a setting in which we are treating many more people by phone, which is likely going to be less expensive and more easily spread throughout the region.
So the first goal is to evaluate the cost and benefits of this intervention, and see what works in the real world, not just in a research setting.
If it does works, then we would like to see it rolled out nationwide. We are not testing in some super complicated, super expensive form that couldn't be done anywhere else. We are testing it as a relatively simple phone call and evaluation and referral. The hope is, if the results merit it, that this will be adopted in other regions.
SM: That last point I think is very important. The way we are studying this is consistent with the way that services are often delivered in VA. So we are hoping that this will make it attractive to the broader health care system because they will be able to relate to it. From an implementation standpoint, it won't be discrepant with what is commonly done here.
MR: Sometimes it is hard to get health care systems to do things that will bring long-term benefits because the problems are subtle or the harms are long term. The harm from the opioid epidemic isn't subtle, and there's a real consensus that we need to treat pain better, and intervene early. In this case, I don't think it will be hard to convince decision makers that early, better pain treatment is necessary; this is a cause that people have embraced.
SM: The other feature of this study that I think will be attractive to providers is we are creating a model where the providers are not going to be asked to do much more than what they are already doing. We are creating a system that complements what they are doing. One of the things that you hear constantly when you try to bring more behavioral interventions into medical centers is "We are too busy." They are very taxed. Asking them to do one more thing that is often seen as outside of their usual scope of practice is a difficult ask. So this is something that we think clinicians have not only embraced as a goal, but have embraced because it is not taxing all the other duties and responsibilities that they have.
